Healthcare Provider Details

I. General information

NPI: 1699649533
Provider Name (Legal Business Name): JENNA PALACIOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 LONG BEACH BLVD STE 330
LONG BEACH CA
90807-3346
US

IV. Provider business mailing address

2436 E 4TH ST # 191
LONG BEACH CA
90814-1156
US

V. Phone/Fax

Practice location:
  • Phone: 562-285-7513
  • Fax:
Mailing address:
  • Phone: 562-285-7513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number4299
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number4299
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: